Table 1.

Virtual meeting results

Location	Phase	Lockdown a	Screening	Management at admission	Surgical prioritization	Alternatives	Reconstruction	Outpatients
China	/	January 23	Stopped	Travel History Clinical history Temperature screening CT scan; nucleic acid detection from samples of throat swabs One patient one single room Mask to all patients	Surgical procedures that cannot be postponed: patients finishing NAC, cancer progressing during NAC, DCIS, malignant tumor such as sarcoma or malignant phyllodes tumor	NAC according to standard criteria	Simplify reconstruction method (only implant‐based reconstruction, or tissue expander if possible PMRT) to reduce risks of complications and shorten time of exposure Decrease robot/free flap reconstruction	WeChat group/e‐mail used during emergency Self‐protection and social distancing advised
Italy (Lombardy)	II	March 15	Stopped	Clinical history Temperature screening, blood check, SpO2, x‐ray Eventual swab or low‐dose CT in selected cases Suspicious cases were postponed (1–2 weeks) Visits mainly for pre‐ and postoperative patients “Hub and spokes” hospital model	In 2–4 weeks: cancer progressing during NAC; premenopausal patients with aggressive disease not candidate for NAC, local‐regional recurrence within 48 months, pregnant patients, patients with complications In 4 and 8 weeks: grade 2 tumors, premenopausal patients with T < 3 cm, N0 cancer not candidate for NAC, patients who have finished neoadjuvant therapy >8 weeks: grade 1 tumors, DCIS, benign disease	NAC according to standard criteria Endocrine therapy as a bridge to surgery in ER+ tumors out of priority criteria Outside standards MDT decision is needed	Only immediate implant‐based reconstruction after mastectomy is allowed	Postsurgery and “urgent” visits (3–10 days) E‐mail/phone calls Telemedicine service
Iran	II	March 20	Stopped	Any travel or close contact Clinical history Temperature screening, SpO2 Chest CT and COVID‐19 test only after consultation and for suspicious cases (if positive, admission denied) All procedures done as day cases	Priority A/B A (as soon as possible): drainage of breast abscess, hematoma, ischemic flap B1 (start treatment before the pandemic is over): refractory or progressive case under neoadjuvant therapy, malignant phyllodes tumor, cancer in first trimester of pregnancy, diffuse or big comedo‐type DCIS B2 (if resources are enough): post‐neoadjuvant cases, T1 N0/T2 N1 luminal cases, stage 1 triple negative, discordance biopsy likely to be malignant, recurrent disease, ER− DCIS	NAC according to standards and for chemo/anti‐HER2 agents sensitive irrespective of stage (except for TNBC stage 1) Endocrine therapy for ER+/HER2− (LumA‐like cases), reevaluate after 3 months; ER+ BC finishing NAC with partial/complete clinical, consider converting to endocrine therapy in order to delay surgery versus surgery for 4–8 weeks	No reconstruction	Postsurgery and follow‐up done remotely
Spain (private)	I	March 29	Stopped	Clinical history Temperature screening Contacts If suspicious, admission denied and referred to swab test Negative PCR required to receive surgery Same day discharge Visits mainly for pre‐ and postoperative patients	Surgical procedures that cannot be postponed (patients finishing preoperative systemic treatment)	NAC according to standard criteria Endocrine therapy according to standard criteria and for premenopausal patients with HR+/HER2− ESBC	Implant‐based reconstruction It is offered if low risk of complications (low BMI, no smokers, no comorbidities, <60 years)	Limitations at the waiting room No follow‐up Telematic consultation whenever possible
Spain (academic)	III	March 29	Stopped	Clinical history Temperature screening, contacts history Negative PCR required to receive surgery Same day discharge Visits mainly for pre‐ and postoperative patients	Surgical procedures that cannot be postponed (patients finishing preoperative systemic treatment)	NAC according to standard criteria Endocrine therapy according to standard criteria and for premenopausal patients with HR+/HER2− ESBC	Implant‐based reconstruction	Limitations at the waiting room No follow‐up Telematic consultation whenever possible
U.K. (England)	II	March 23	Stopped	Clinical history Physical examination PCR test, if available, for every patient Recent CT chest (last 24 hours) or, failing that, CXR Clip all cancers when biopsy performed Aim for day case surgery; do minimum Minimum staff in theater; appropriate PPE for all staff All patients are intubated and extubated in theater	Surgical priority given to patients with ER− disease first, then patients with HER2+ disease Post‐NAC High grade DCIS (ER+ started on HT, ER− candidate for surgery) If highly suspicious COVID‐19 infection or positive test, postpone surgery, then reevaluate Incise tumor and mark it to reduce specimen manipulation by pathologists (protect pathologists) All specimens are fixed in formalin	NAC only for inoperable patients Endocrine therapy according to standard criteria and for ER+ DCIS (all core biopsies demonstrating DCIS should be tested for hormone receptor status) Perform genomic testing on the biopsy specimen for invasive breast cancer and consider endocrine therapy ER+/HER2− BC post‐NAC: consider converting to endocrine therapy in order to delay surgery ER+/HER2+ BC post‐NAC: consider converting to NET + anti‐HER2 therapy in order to delay surgery	No reconstruction	Triage all referrals Telephone consultation Face‐to‐face clinic; 5–6 patients per clinic 30‐minute slot each Patients aged ≥70 years or patients with significant comorbidities: no clinic visit Only phone consultation Start empirical HT if suspicious
U.K. (Scotland)	I	March 23	Stopped	COVID‐19 test only for symptomatic patients Clinical history Highly suspicious need PCR testing If safe, perform procedures as day surgery	Surgical priority given to patients with ER− disease first, then patients with HER2+ disease Post‐NAC High grade DCIS (ER+ started on HT, ER− candidate for surgery) If highly suspicious COVID‐19 infection or positive test, postpone surgery 2/52, then reevaluate Incise tumor and mark it to reduce specimen manipulation by pathologists (protect pathologists) All specimens are fixed in formalin	NAC according to standard criteria Endocrine therapy: ER+ DCIS (all core biopsies demonstrating DCIS should be tested for hormone receptor status) ER+/HER2− BC (perform genomic testing on the biopsy specimen, and consider endocrine therapy or NAC if appropriate) ER+/HER2− BC post‐NAC: consider converting to endocrine therapy in order to delay surgery ER+/HER2+ BC post‐NAC: consider converting to NET + anti‐HER2 therapy in order to delay surgery	No reconstruction	All urgent referrals are accepted Routine referrals postponed or cancelled
U.S. (New York City)	II	March 22	Stopped	Telephone triage Clinical history Temperature screening Blood check SpO2 +/‐ COVID‐19 test	Life‐threatening conditions: breast abscess in a patient with sepsis, expanding hematoma Urgent cases: ischemic autologous tissue flap/mastectomy flap, patients who have finished NAC, progression under NAC BCS is preferred, provided that radiation oncology services are available and the risk of multiple visits or deferred radiation is acceptable If no ventilator available or high risk of exposure, BCS can be performed under local anesthesia via sedation	NAC for TNBC/HER2+ (≥ T2 or N1) Some ER+/HER2− Inflammatory/ locally advanced BC Endocrine therapy: ER+ DCIS (all core biopsies demonstrating DCIS should be tested for hormone receptor status) ER+/HER2− BC (perform genomic testing on the biopsy specimen, and consider endocrine therapy or NAC if appropriate) ER+/HER2− BC post‐NAC: consider converting to endocrine therapy in order to delay surgery ER+/HER2+ BC post‐NAC: consider converting to NET + anti‐HER2 therapy in order to delay surgery	Limited to tissue expander or definitive implant placement Autologous reconstruction should be deferred	The majority of encounters are conducted remotely via telemedicine If need for in‐person evaluation special measures to reduce the risk of infection are put in place
Sweden	I		Decision on a regional level; decreased participation	COVID‐19 test only for symptomatic patients If medically safe, perform procedures as day surgery	Priority as follows: patients who have completed or discontinued primary chemotherapy, then TNBC, HER2+, then LumB, then LumA, DCIS grade 3 with larger size	NAC according to standard criteria Endocrine therapy: >70 yr, LumA or B N0/1 60–70 yr, LumA N0	Perform breast reconstruction in exceptional cases; choose the simplest alternative	Only absolutely necessary referrals Calls, video calls when appropriate
Denmark	I	March 12	Unchanged	COVID‐19 test only for symptomatic patients	BIRADS 4 and 5 lesions treated as always BIRADS 3 treated on MDT decision BIRADS 1–2 postponed	NAC according to standard criteria Patients informed on potential risks of chemotherapy during the COVID‐19 pandemic	As usual, some limitations for the DIEP flap	Normal consultations (only distancing) for BIRADS 4–5 and some BIRADS 3
Switzerland (Italian‐speaking part)	I	March 16	Stopped	COVID‐19 test for all symptomatic patients within 48 hours before surgery	Standard indications to surgery	NAC, including immune and endocrine therapy according to standard criteria	Standard indications for breast reconstruction if beneficial for patient, including autologous reconstruction	Consultations limited to only not deferrable ones Most consultations via telephone, video calls or e‐mail
Portugal	I	March 18	Stopped	Clinical history Physical examination Temperature screening Chest x‐ray WBC COVID‐19 test for all symptomatic patients	Patients completing NAC Only level I oncoplastic breast conserving surgery	NAC according to standard criteria	No reconstruction	Urgent referrals only Face masks for all patients and social distance in waiting room

^aLockdown dates as reported on https://en.wikipedia.org/wiki/Curfews_and_lockdowns_related_to_the_2019%E2%80%9320_coronavirus_pandemic (except for Iran).

Abbreviations: BC, breast cancer; BCS, Breast Conserving Surgery; BIRADS, Breast Imaging–Reporting and Data System; BMI, body mass index; CT, computed tomography; CXR, Chest X Ray; DCIS, ductal carcinoma in situ; DIEP, deep inferior epigastric perforator; ER, estrogen receptor; ESBC, early stage breast cancer; HER2, human epidermal growth factor receptor 2; HR, hormone receptor; HT, hormonal therapy; LumA, luminal A; LumB, luminal B; MDT, multidisciplinary team; NAC, neoadjuvant chemotherapy; NET, Neoadjuvant Endocrine Therapy; PCR, polymerase chain reaction; PMRT, postmastectomy radiotherapy; PPE, personal protection equipment; SpO2, oxygen saturation; TNBC, triple‐negative breast cancer; WBC, white blood cells.